Welsh NHS Confederation’s Health and Wellbeing Alliance Mental Health Sub-Group response to the inquiry into mental health inequalities
Introduction
1. The Welsh NHS Confederation Health and Wellbeing Alliance’s Mental Health Sub-Group welcomes this inquiry into mental health inequalities and is encouraged by this focus from the Health and Social Care Committee. The group brings together the views of Royal Colleges and third sector organisations in Wales and creates a collective voice around mental health related issues. There are a number of opportunities to address mental health inequalities, including through embedding measures around this into the next iteration of the long-term strategy for mental health and through Health Education and Improvement Wales (HEIW) and Social Care Wales’ Mental Health Workforce Strategy.
2. As highlighted within the Alliance briefing, Making the difference: Tackling health inequalities in Wales, mental health inequalities are the result of a myriad of factors and meaningful progress will require coherent efforts across all sectors.
3. The group identified tackling mental health inequalities as a priority at the outset and calls for urgent action from decision and policy makers in Wales. We call on the Welsh Government to take cross-government action to tackle mental health inequalities by pulling together a delivery plan that outlines the action being taken across all government departments, how success will be measured and evaluated, and how individual organisations should collaborate across Wales to reduce health inequalities and tackle the cost-of-living crisis.
4. This response covers all four questions by high-risk group, and maps out prevalence of mental health problems and the inequity of access and outcomes experienced by certain groups.
Inequity of prevalence, access, and outcomes
5. Covid has driven an increase in poor mental health.[1] This is a result of existing inequalities and health conditions being exacerbated by the pandemic, as well as restrictions to lifestyle, loss of work and role, loss of usual social support, and social isolation.
6. However, we know that there are groups of people who are disproportionately affected by poor mental health and subsequent suicide risk in Wales. Below we will give further detail on this and will highlight the factors that contribute to worse mental health within these groups. We will also offer a number of recommendations to help the committee and Welsh Government respond urgently to mental health inequalities.
Poverty
7. Mental health conditions often interact with and include biological, psychological, environmental, economic and social elements. The clearest evidence of this is the well-established overlap between those who experience mental health conditions and indicators of poverty e.g. poor housing, low income and poor educational attainment. In Wales’ most deprived neighbourhoods, suicide rates are between two and three times higher compared to the most affluent.[2]
8. People receiving benefits were more likely to experience poor mental health before the pandemic. A survey by Mind Cymru found that over half (59%) of survey participants living in a household receiving benefits said they currently had poor or very poor mental health (vs 34% of those not receiving benefits).[3] Citizens Advice Cymru found that almost 80% of the people who sought advice said their problems made them feel stressed or anxious.
Recommendations:
- There should be coherent cross-sector and cross-government action to tackle mental health inequalities, including addressing the social determinants of mental health.
- Advice services should be co-located in mental health settings, so that people can receive the right support at the right time and the root cause of their problem can be dealt with appropriately.
Children and young people
9. Child health outcomes are the product of complex, inter-connected social, economic, personal and political factors. An individual child’s health is inevitably influenced by the world and environment around them, not only by the quality of care they receive from the health system, but also by the services they are able to access and by their family’s lifestyle.
10. Children are experiencing a high level of mental ill health. Research from Cardiff University found 1 in 5 children experienced poor mental health prior to the COVID-19 pandemic.[1] The research further identified poor mental health was higher if:
- The child was a girl, with a significant gender difference by year 10,
- If the child was from a less affluent family,
- If the child did not identify as either a boy or a girl.[2]
11. The COVID-19 pandemic has also had a disproportionate impact on those already experiencing mental ill health. Mind Cymru found that 45% of young people who responded to their survey (2021) have self-harmed to cope with the pandemic, making them more than three times as likely as adults (12%) to cope in this way.[1] Research also highlights that Adverse Childhood Experiences (ACEs) have harmful impacts on health and well-being across the life course.[2] Preventing ACEs in future generations could reduce levels of low mental well-being by 27%.[3]
12. Research shows that children who are abused or neglected are four times more likely to develop a serious mental health need and twice as likely to develop some form of mental illness, such as depression or anxiety. [6]The consequences of this can last across their life course. Studies also suggest that exposure to interpersonal traumas, such as violence and abuse are associated with higher rates of PTSD.[7] NSPCC evidence shows that 1 in 5 children are exposed to domestic abuse[8] and almost 1 in 10 to child sexual abuse.[9] The nature of domestic abuse can create barriers to anyone accessing support. The perpetrator creates a controlling and frightening environment, where the non-abusing parent and child have their space for action reduced. NSPCC Cymru has consistently highlighted its concern about the ‘postcode lottery’ of service provision for children and young people across Wales; both crisis intervention and, crucially for this agenda, therapeutic recovery.
13. In terms of child sexual abuse, NSPCC research highlights that it can take an average of seven years for a child to disclose abuse and some many never tell anyone.[1] This of course creates a huge barrier to accessing any form of support. When children do reach out, many disclosures are not recognised or understood or they can be dismissed, played down or ignored, meaning action is not taken to support the young person.[2]
Recommendations:
- It’s crucial that the Health and Social Care Committee inquiry into mental health should engage with the Children, Young People and Education Committee to understand the impact on services for young people and fully address any barriers to access. This would allow for inquiries which range across the entire breadth of mental health provision.
- It’s widely acknowledged that the new curriculum and the whole school approach is a unique opportunity to improve the mental health of this population, particularly with mental health being on the face of the bill. However, schools need ongoing support and guidance in order to realise this opportunity and reach the vulnerable school population.
- We need to bolster community delivered care for children and young people, as well as CAMHS by ensuring there is investment in the specialist and wider mental health workforce and mental health estate.
- Recovery support for the highly traumatised cohort of children who have been abused must be specialist and services must be fully resourced to meet need. Where children and young people are accessing existing mental health services, professionals need to feel equipped to support appropriately with an understanding of how experiences of abuse can manifest and impact mental health.
Black, ethnic minority groups
14. It is now clear that experience of discrimination and inequality can increase the risk of developing mental illness. People who are subject to inequality go through life with higher levels of stress and mental distress, which places them at higher risk of attempted suicide and self-harm. Much more needs to be done to shape the mental health services to meet the needs of a diverse population
15. We know that people from ethnic minority groups are at increased risk of involuntary psychiatric detention:
- People of Black Caribbean and Black African heritage are all significantly more likely to be compulsorily admitted than White ethnic groups.
- Those from Black Caribbean backgrounds were also significantly more likely to be readmitted.
- South Asian and East Asian people are also significantly more likely to be compulsorily admitted than people from White British backgrounds.
- Migrants from all backgrounds are also significantly more likely to be compulsorily admitted.
- There is a growing body of research to suggest that those exposed to racism may be more likely to experience mental health problems such as psychosis and depression.
- Young African-Caribbean men are more likely to access mental healthcare in crisis and to be admitted via criminal justice routes.
- Adults from South Asia are least likely to be referred to specialist services, despite being frequent consulters of primary care. Research suggests this may be related to a lack of culturally appropriate services.
- Recovery rates following psychological therapies are higher among White British people compared to people of all other ethnicities.[1]
- Women from ethnic minority groups are also at greater risk of experiencing perinatal mental health problems[i], but are less likely to have them detected or treated[ii], facing language difficulties, stigma and a lack of culturally sensitive provision as key barriers.
Recommendation:
- Welsh Government should continue to work with UK Government on the reforms to the Mental Health Act to ensure a joined-up approach across public services.
LGBTQ+ individuals
16. LGBTQ+ individuals have a higher risk of suicidality yet experience discrimination when accessing healthcare. Among LGBTQ+ young people, 7 out of 10 girls and 6 out of 10 boys described having suicidal thoughts.[1] They were around three times more likely than others to have made a suicide attempt at some point in their life.[2] Transgender young people are at particular risk of experiencing poor mental health. The Stonewall School Report Cymru (2017) shows that three in four trans young people (77 per cent) have deliberately harmed themselves, nine in ten (92 per cent) have thought about taking their own life, and two in five (41 per cent) have attempted to take their own life. Childline data also indicates that in 2020/21, in 38% of counselling sessions about sexuality or gender identity, young people talked about mental and emotional health needs. These unacceptably high levels of poor mental health are as a result of bullying, social stigma, discrimination and other challenges which may not be encountered by those who identify as heterosexual and cisgender.
17. The experiences of LGBTQ+ young people must be considered when planning a recovery response to COVID-19, particularly on the mental health impacts of lockdown and social distancing. Mental health support services, particularly CAMHS, need to be improved across the board, but there are particular barriers for LGBTQ+ young people. Action within the LGBTQ+ Action Plan for Wales (2021) to ensure that any future review of mental health services takes account of the focus on and efficacy for LGBTQ+ people including young people, is welcome. Mental health services should always be LGBTQ+ friendly and there should be regular training on how practitioners can be sensitive to the needs.
18. Inclusive LGBTQ+ friendly Relationship and Sexuality Education (RSE) will have a positive impact on LGBTQ+ young people, and help to support their mental health and keep them safe from harm.
Recommendations:
- The Welsh Government should invest in a high-quality programme of professional learning to support teachers to be skilled and confident in designing and delivering inclusive RSE.
- Clarity is needed on how much will be invested in professional learning on designing a fully LGBTQ+ inclusive curriculum, over what time period, and what this training will include. Investment in evidence-based LGBTQ+ resources to support the design of an inclusive curriculum is also essential.
Older people
19. The World Health Organisation (WHO) reported that approximately 20% of people aged 60 or over have a mental health illness. The two most common illnesses are depression (7%) and dementia (5%).[1]
20. There have been a number of instances where older people’s mental health has been neglected. The Ockenden report (2015), investigated patient safety in the older people mental health ward, Tawel Fan following significant concerns from families and staff. The report identified, among other things, that the ward had struggled to maintain appropriate staffing levels and subsequent patient safety.[2]
Recommendations:
- To improve services in order to reduce these inequalities it is important that services are co-designed with the people the services are intended to support
- Services should be both universal across all aspects of life, and targeted, so that they are shaped and placed according to the needs of local population groups.
Women
21. On average, women in Wales exhibited worse levels of mental health after the onset of the pandemic, with the gap between reported wellbeing between men and women increasing from 9.9% to 14.1%.[1]
22. Many women and girls who have experienced forms of Violence Against Women (VAW) are deeply traumatised and go on to face multiple, complex issues. The links between violence and abuse and poor mental health are unambiguous. Research by Agenda shows that over half (54%) of women with extensive experience of physical and sexual violence meet the diagnostic criteria for at least one Common Mental Disorder, and are also more likely to have multiple conditions with about one in seven (15%) having three or more mental disorders. Over a third (36%) of women in the extensive physical and sexual violence group have made a suicide attempt, and a fifth (22%) have self-harmed. One in ten (9%) have spent time on a mental health ward.[2]
23. Gender inequality is both a cause and a consequence of women and girls’ unequal mental health outcomes. Women and girls face inequality and discrimination both in their daily interactions and through systems and institutions, which have often been designed around a male service-user by default, and can sometimes be male dominated (e.g. drug and alcohol services). Being systematically subordinated and disempowered has long-term psychological effects. There is wide research evidencing the links between experiencing discrimination and poor mental health: including depression,[3] anxiety and psychological stress,[4] and Post-traumatic stress disorder (PTSD).[5]
24. New and expectant mums are also disproportionately at risk of experiencing poor mental health. Pregnancy and the postpartum period are times of increased vulnerability for both the onset and relapse of mental health problems. Perinatal mental health problems are the most common complication of childbearing[6], with up to 1 in 5 mums affected in the UK.[7] This is a real concern; if left untreated, perinatal mental health problems can have a devastating impact on the mental and physical health of women, partners and babies. Evidence also shows that the COVID-19 pandemic has increased the risk of women and families experiencing perinatal mental health problems
25. In order to effectively meet women’s health needs, both mental and physical, it is essential that a trauma-informed approach be delivered across services to ensure women and girls get the support they need.
Recommendations:
- Staff education and training across health services should take a trauma-informed approach, and should cover a gendered approach to trauma including violence and abuse, and wider inequalities
- The mental health impact of violence against women and girls should be explicitly addressed, through a cross-department approach. This should be incorporated into a future mental health strategy for Wales following on from Together for Mental Health.
- Clear and safe information recording and sharing about experiences of violence and abuse and related issues should be consistently implemented across health services to avoid the re-traumatisation of women having to repeatedly re-tell their stories.
- The reduction of the use of physical restraint in inpatient mental health services, which can be particularly distressing for those who have experienced trauma should be prioritised, with a Wales-wide ban on the use of face-down restraint
- Women-only peer support to be commissioned and delivered as a core component of all wider interventions to support women and girls’ mental health.
- Further investment in perinatal mental health, to ensure all services can meet CCQI perinatal quality network standards; for each health board to have a specialist perinatal mental health midwife and health visitor, and for there to be an accessible MBU for all women and families that need it.
Children and adults with communication and speech and language difficulties
26.Research also highlights Children with a mental health disorder are five times more likely to have problems with speech and language (NHS Digital, 2018)3 and 81% of children with social, emotional and mental health needs have significant unidentified language deficits (Hollo et al, 2014).4 Adolescents and young adults with developmental language disorder (DLD) are more likely to experience anxiety and depression than their peers (Conti-Ramsden at al, 2008; Botting et al, 2016).
27. 80% of adults with mental health disorders have impairment in language (Walsh et al, 2007) and over 60% have impairment in communication and discourse (Walsh et al, 2007). Likewise, over 30% of adults with mental health disorders have some impairment in swallowing (Walsh et al, 2007). There is a greater prevalence of dysphagia (swallowing difficulties) in acute and community mental health settings compared to the general population - 35% in an inpatient unit and 27% in those attending day hospital, which compares to 6% in the general population (Regan et al, 2006).
Recommendations:
- The Health Education and Improvement Wales and Social Care Wales mental health workforce plan should include key actions to grow the speech and language therapy workforce working in core mental health services. This area should also considered within the revised Together for Mental Health plan.
Prison populations
28. The prevalence of mental ill health within prison settings is higher than in the general population and is often neglected.
29. Data regarding people in Welsh prisons is extremely poor as it is often merged with England and gathered sporadically. An estimate of 36% of prisoners across Wales and England were considered to have a disability when surveyed as part of the surveyed prisoner crime reduction survey between 2005/2006; this compared to 19% of the general population. The 36% included 18% with anxiety and depression, 11% with some form of physical disability and 8% with both.[1]
30. However it is known that in England and Wales between 2010 and 2020 the rate of self-harm incidents in prisons more than doubled from 26,983 incidents to 61,153 incidents.[2]
31. The responsibility for prison health care in Wales rests with the Welsh Government. At a local level, prison health partnership boards, jointly chaired by local health boards and the governors of the prisons, have responsibility for the governance of prison health services.
Severe mental illness (SMI): co-morbidities and life expectancy
32. Approximately 1 in 50 people in Wales has a severe mental illness such as schizophrenia or bipolar disorder.[3] The exact number of people experiencing severe and enduring mental illness is largely unknown as the Welsh Government do not gather this information centrally. What we do know is that there are 31,597 people registered as having a mental health illness on the GP Quality and Outcome Framework (QOF), although the breakdown is not provided.
33. Mental health problems can influence education, development, employment and physical health. It is not only mental health issues that are affected by the current lack of services, but as we know, the presentation of other health conditions has decreased. This includes fewer patients presenting with new cancers, heart attack, and stroke.
34. People with SMI are at a greater risk of poor physical health and die on average 15 to 20 years earlier than the general population.[1] It is estimated that for people with SMI, 2 in 3 deaths are from physical illnesses that can be prevented.[2] Major causes of death in people with SMI include chronic physical medical conditions such as cardiovascular disease, respiratory disease, diabetes and hypertension. Patients with mental health problems are at greater risk of developing these issues due to a generally higher prevalence of smoking, side effects of antipsychotic drugs, and lack of engagement with screening problems. In addition, this patient group traditionally has poorly engaged with healthcare services, especially cancer screening programmes and health promotion such as smoking cessation advice. As a result, it’s crucial that routine physical health monitoring is available and accessible to people with SMI.
Recommendations:
- The Welsh Government must invest in all secondary and specialist mental health services to reduce the stigma and inequalities experienced by people with severe and enduring mental illness
- The Welsh Government must review the pressures facing mental health services in Wales: this includes the interface with the Criminal Justice System, the increased use of the Mental Health Act (MHA), as well as inpatient services, out of area placements and the response to individuals in crisis
- It’s crucial that individuals living with severe mental illnesses and learning disabilities receive routine physical assessments to identify and treat physical co-morbidities and prevent early death.
- As recommended in the National Clinical Audit of Psychosis, Welsh Government should expand the Individual Placement and Support (IPS) programme to a national offer, supporting people with severe and enduring mental illness into employment.[3]
35. Finally, it is clear that the policy changes needed to tackle mental health inequalities do not belong to any one sector, Government department or Senedd committee. Mental health inequalities are strongly linked to social justice, welfare, housing, early years and education. As such, the Welsh Government should take cross-government action to tackle mental health inequalities by pulling together a delivery plan that outlines the action being taken across all Government departments, how success will be measured and evaluated, and how individual organisations should collaborate across Wales to reduce health inequalities and tackle the cost-of-living crisis.
This response is endorsed by:
Citizens Advice Cymru
Community Housing Cymru
Fair Treatment for the Women of Wales
Learning Disability Wales
Mind Cymru
MS Society
National Autistic Society Cymru
NSPCC Cymru/ Wales
Royal College of Nursing Wales
Royal College of Physicians Cymru/Wales
Royal College of Psychiatrists Wales
Royal College of Speech and Language Therapists
Samaritans Cymru
Welsh NHS Confederation
References:
[1] The Lancet, Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population, July 2020
[2] Socioeconomic_disadvantage_and_suicidal_behaviour_bilingual.pdf (samaritans.org)
[3] the-consequences-of-coronavirus-for-mental-health-in-wales-final-report.pdf (mind.org.uk)
[7] ACE & Mental Wellbeing Infog (7).pdf (phwwhocc.co.uk)
[8] ACE & Mental Wellbeing Infog (7).pdf (phwwhocc.co.uk)
[9] Chandan, J, S., Thomas, T., Gokhale, K, M., and Bandyopadhya, S (2019) The burden of mental ill health associated with childhood maltreatment in the UK, using The Health Improvement Network database: a population-based retrospective cohort study. The Lancet, 6(11), 926-934
[10] Duffy, M., Walsh, C., Mulholland, C., Davidson, G., Best, P., Bunting, L., Herron, S., Quinn, P., Gillanders, C., Sheehan, C., and Devaney, J (2021) Screening Children with a History of Maltreatment for PTSD in Frontline Social Care Organizations: an Exploratory Study. Child Abuse Review 30(6) pp. 594–611
[11] Women’s Aid (2020) Children Matter: Children and young people experience violence and abuse too. Accessed at: Children-and-Young-People-participation-report-FINAL.pdf (welshwomensaid.org.uk)
[12] ONS (2019) Estimated number and proportion of adults aged 18 to 74 in Wales who experienced abuse before the age of 16, year ending March 2019 CSEW - Office for National Statistics (ons.gov.uk)
[13] Allnock, D. and Miller, P. (2013) No one noticed, no one heard: a study of disclosures of childhood abuse. London: NSPCC. Accessed at: https://learning.nspcc.org.uk/media/1052/no-one-noticed-no-one-heard-report.pdf
[14] Ibid
[15]equality-action-plan---january-2021.pdf (rcpsych.ac.uk)
[16] equality-action-plan---january-2021.pdf (rcpsych.ac.uk)
[17] equality-action-plan---january-2021.pdf (rcpsych.ac.uk)
[18] https://www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults
[20] Cardiff University (2021) Covid-19 in Wales: the mental health and wellbeing impact
[21] Agenda (2016) Hidden Hurt
[22] Vigod, S. N (2020) The impact of gender discrimination on a Woman's Mental Health
[23] Paradies Y, Priest N, Ben J, Truong M, Gupta A, Pieterse A, Kelaher M, Gee G. (2015) Racism as a Determinant of Health: A Systematic Review and Meta-Analysis
[24] Wilson, E. C. et al (2017) The impact of discrimination on the mental health of trans*female youth and the protective effect of parental support
[25] Howard, L and Khalifeh, H (2020) Perinatal mental health; a review of progress and challenges. World Psychiatry 19(3): 313-327
[26] Bauer, A., Parsonage, M., Knapp, M., Iemmi, V., and Adelaja, B (2014) The costs of perinatal mental health problems. Centre for Mental Health and London School of Economics.
[27] See for example: Babies in Lockdown: listening to parents to build back better (2020). Best Beginnings, Home-Start UK, and the Parent-Infant Foundation; Das, R (2020) COVID-19, perinatal mental health and the digital pivot. Findings from a qualitative project and recommendations for a ‘new normal’. University of Surrey; Davenport, M.H., Meyer, S., Meah, V. L., Strynadka, M.C and Khurana, R (2020) Moms Are Not OK: COVID-10 and Maternal Mental Health. Frontiers in Global Women’s Health. 1 (1): 1-6; Papworth, R., Harris, A., Durcan, G., Wilton, J., and and Curtis Sinclair, C (2021) Maternal mental health during a pandemic: A rapid evidence review of Covid-19's impact. Centre for Mental Health. Maternal Mental Health Alliance; Thapa, S. B., Mainali, A., Schwank, S. E and Acharya, G (2020) Maternal mental health in the time of the COVID-19 pandemic. Acta Obstet Gynecol Scand. 99 (7): 817-818
[28] Data for this report come from Surveying Prisoner Crime Reduction (SPCR)
[29] Mental health in prison inquiry launched - Mental Health Wales
[30] together-for-mental-health-summary.pdf (gov.wales)
[31] People with severe mental illness experience worse physical health - GOV.UK (www.gov.uk)
[32] (The Mental Health Taskforce, NHS England. ‘Five Year Forward View for Mental Health’ 2016).
[33] ncap-spotlight-audit-report-on-employment-2021-(2).pdf (rcpsych.ac.uk)
i Watson, H., Harrop, D., Walton, E., Young A, and Soltani, H (2019) A systematic review of ethnic minority women’s experiences of perinatal mental health conditions and services in Europe. PLoS ONE, 14(1): 1-9
ii Edge, D (2011) Perinatal Mental Health of Black and Minority Ethnic Women: A Review of Current Provision in England, Scotland and Wales, National Mental Health Development Unit. Available at: dh_124880.pdf (publishing.service.gov.uk); Prady, S., Pickett, K., Petherick, E., Gilbody, S., Croudace, T., Mason, D., and Wright, J. (2016) Evaluation of ethnic disparities in detection of depression and anxiety in primary care during the maternal period: Combined analysis of routine and cohort data. British Journal of Psychiatry, 208(5): 453-461
